Failure to Prevent Unnecessary Antibiotic Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary antibiotic therapy, as required by regulations. For one resident, antibiotics were prescribed for a urinary tract infection (UTI) based on a single low-grade fever recorded ten days prior, with no culture and sensitivity (C&S) test performed and no clear documentation of infection criteria being met. Another resident received antibiotics for a UTI despite only exhibiting altered mental status, with no C&S ordered and documentation indicating that antibiotic stewardship guidelines were not followed. In both cases, the infection control preventionist (ICP) and the director of nursing (DON) could not provide justification for the antibiotic use or explain the rationale for the chosen therapy in the absence of confirmed infection. A third resident was started on antibiotics for a UTI based on an abnormal urinalysis, with the C&S later returning negative for infection. Despite this, the resident continued to receive the full course of antibiotics. The ICP acknowledged that antibiotics should have been discontinued once the negative C&S result was received but could not explain why this did not occur. In all three cases, documentation indicated that infection criteria were not met, and antibiotics were administered without appropriate clinical justification or supporting laboratory evidence.
Plan Of Correction
F 757 1.) Resident #40, #85, and #86 were assessed by the nurse manager and no acute issues noted. 2.) A one-time audit was completed on ABT within the last 14 days to ensure they meet McGreer's criteria or have a risk versus benefits completed. The licensed nurses and providers were re-educated on McGreer's criteria. 3.) System change: Mon-Friday during the clinical meeting the ICP/Designee will review ABT to ensure they are meeting McGreer's criteria. 4.) DON/Designee will review 5 ABT weekly x 12 weeks then monthly x 3 months to ensure McGreer's criteria is met. Any non-adherence will result in 1:1 education. All audits will be brought to the QA committee for review and further recommendations. The Director of Nursing will be responsible for ongoing sustained compliance.